COVID-19 and aorto-enteric fistula.

We present the case of a 72-year-old male with upper gastrointestinal bleeding. He had been discharged from hospital two weeks before after severe COVID-19 infection, treated with lopinavir-ritonavir (L-R), hydroxychloroquine, tocilizumab, and methylprednisolone. On presentation, he was in hypovolemic shock. Esophagogastroduodenoscopy showed an ulcer in the third duodenal portion, which was sclerosed and hemodynamic stability was recovered. A scan was performed as it was in an atypical location for ulcers, showing an aortic aneurysm in close relationship to the duodenum, suggesting a primary aortoenteric fistula (PAEF).

Ultrasound Surveillance in Endovascular Revascularization of Lower Limbs.

BACKGROUND: Endovascular surgery has become the initial treatment for most patients with chronic ischemia of the lower limbs. Few studies support ultrasound surveillance (US) of this kind of procedures. The purpose of this study was to evaluate the initial efficacy of duplex ultrasound as a surveillance method in endovascular treatment in symptomatic peripheral arterial disease patients in our center. MATERIAL AND METHODS: A total of 113 endovascular procedures performed in 106 patients between February 2013 and June 2015 were included. Follow-up included clinical assessment, physical examination, ankle-brachial index (ABI), plethysmography, and ultrasound at 1, 3, 6, 12, 18, and 24 months after surgery. Patients without a minimum follow-up of two controls were excluded. Worsening was defined as follows: (1) in ultrasound, a restenosis >70%; (2) from ABI, a decrease >0.15; (3) clinically, a decrease in claudication distance, reappearance rest pain, or worsening injuries; (4) in plethysmography, flattening in the curve. RESULTS: The average age was 68.3 years, with 72% being men. Twenty-two percent of treated lesions were iliac, 57% were femoropopliteal, and 21% were distal. There were 329 visits, with a mean follow-up of 13.5 months (3-31). The US detected permeability or moderate stenosis in 66 patients (58.4%) and restenosis or occlusion in 47 (41.6%). When compared with clinical status, there was a noncorrelation in 23% and a discrepancy with respect to the ABI of 27% and of 39% with plethysmography. All these differences were statistically significant (P < 0.001). Twenty-one reinterventions were performed (18.6%), six patients died (5.3%), and 11 required major amputation (9.7%). CONCLUSIONS: Clinical status and hemodynamics can detect restenosis or occlusion of the procedure in a large part of the cases, but it can omit more than 20% of these that were only detected by US. The ultrasound follow-up is of great help to increase the reliability of the control in patients with endovascular revascularization of lower limbs.

Contrast-Enhanced Ultrasound in Vascular Surgery: Review and Update.

Accurate imaging methods associated with minimum patient risk are important tools for clinical decision-making in vascular surgery. Today, traditional imaging methods, such as computed tomography angiography, magnetic resonance angiography, and digital subtraction angiography are the preferred modalities. Ultrasound has only challenged these methods in assessment of carotid disease, aortic aneurysms, venous insufficiency, and thromboembolism and in surveillance of in situ bypasses. These practice patterns may change with the introduction of second-generation ultrasound contrast agents which are easy to use, manageable, and safe. This topical review attempts to summarize and highlight the current evidence and future prospects for contrast-enhanced ultrasound in vascular surgery, with a particular focus on opportunities in carotid and lower limb arteriosclerotic disease and surveillance after endovascular aneurysm repair.

Contrast-Induced Nephropathy: A Fact or Fiction in Lower Limb Revascularization?

INTRODUCTION: Contrast-induced nephropathy (CIN) is defined as an increase >25% of serum creatinine from baseline, occurring in 24-48 hours after exposure to contrast, while alternative explanations for renal impairment have been excluded. The volume administered directly relates to risk, increasing by 12% per 100 mL of contrast. According to the series, its incidence varies between 3.3% and 8% in patients without renal damage and 12-50% in patients with chronic kidney disease (CKD) and/or diabetes mellitus (DM). The purpose of this study is to determine the incidence of CIN in endovascular revascularization of lower limbs in our center, where we apply the ALARA concept (As Low As Reasonably Achievable) to the use of contrast. MATERIAL AND METHODS: 163 patients who underwent endovascular revascularization procedures in lower limbs were included in this prospective observational study between February 2013 and April 2015. They were classified according to clinical stage and presence of DM and/or CKD. Data included serum creatinine values preoperative and postoperative, type and volume of contrast used. Patients on hemodialysis and those without sufficient analytical data were excluded. Chi-squared test and Student t-test were used for data analysis. P < 0.05 was considered statistically significant. RESULTS: 109 patients were enrolled, with 67% of DM and 31.5% of CKD. CIN incidence was 3.7% in patients without DM neither CKD, in DM was 6.8% and 12.5% in CKD. Mean creatinine presurgery was 97.96 and postsurgery 97.07, finding no significant differences between them (P = 0.753). Medium-contrast volume was 37.43 mL ± 22.3. The worsening variable (creatinine postsurgery minus creatinine presurgery) was evaluated according to clinical stage, DM, or CKD, being not significant in either group. CONCLUSIONS: In our experience, the dose administered of contrast was not related to the existence of postprocedure CIN, due to the policy of optimizing the use of contrast.

Cardiac rehabilitation and outcome in stable outpatients with recent myocardial infarction.

OBJECTIVE: To compare the mortality rate and the rate of subsequent ischemic events (myocardial infarction [MI], ischemic stroke, or limb amputation) in patients with recent MI according to the use of cardiac rehabilitation or no rehabilitation. DESIGN: Longitudinal observational study. SETTING: Ongoing registry of outpatients. PARTICIPANTS: Patients (N=1043) with recent acute MI were recruited; of these, 521 (50%) participated in cardiac rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Subsequent ischemic events and mortality rates were registered. RESULTS: Over a mean follow-up of 18 months, 50 patients (4.8%) died and 49 (4.7%) developed 52 subsequent ischemic events (MI: n=43, ischemic stroke: n=6, limb amputation: n=3). Both the mortality rate (.16 vs 5.57 deaths per 100 patient-years; rate ratio=.03; 95% confidence interval [CI], 0.0-0.1]) and the rate of subsequent ischemic events (1.65 vs 4.54 events per 100 patient-years; rate ratio=0.4; 95% CI, 0.2-0.7) were significantly lower in cardiac rehabilitation participants than in nonparticipants. Multivariate analysis confirmed that patients in cardiac rehabilitation had a significantly lower risk of death (hazard ratio=.08; 95% CI, .01-.63; P=.016) and a nonsignificant lower risk of subsequent ischemic events (hazard ratio=.65; 95% CI, .30-1.42). CONCLUSIONS: The use of cardiac rehabilitation in patients with recent MI was independently associated with a significant decrease in the mortality rate and a nonsignificant decrease in the rate of subsequent ischemic events.

Soluble ST2 serum concentration and renal function in heart failure.

BACKGROUND: Soluble ST2 (sST2) provides important prognostic information in patients with heart failure (HF). How sST2 serum concentration is related to renal function is uncertain. We evaluated the association between sST2 and renal function and compared its prognostic value in HF patients with renal insufficiency. METHODS AND RESULTS: Patients (n = 879; median age 70.4 years; 71.8% men) were divided into 3 subgroups according to estimated glomerular filtration rate (eGFR): ≥60 mL/min/1.73 m(2) (n = 337); 30-59 mL/min/1.73 m(2) (n = 352); and <30 mL/min/1.73 m(2) (n = 190). sST2 (rho = -0.16; P < .001), N-terminal pro-B-type natriuretic peptide (rho = -0.40; P < .001), and high-sensitivity cardiac troponin T (rho = -0.47; P < .001) inversely correlated with eGFR. All-cause mortality was the primary end point. During a median follow-up of 3.46 years, 312 patients (35%) died, 246 of them from the subgroup of 542 patients with eGFR <60 mL/min/1.73 m(2) (45%). Biomarker combination including sST2 showed best discrimination, calibration, and reclassification metrics in renal insufficiency patients (net reclassification improvement 16.6 [95% confidence interval (CI) 8.1-25; P < .001]; integrated discrimination improvement 4.2 [95% CI 2.2-6.2; P < .001]). Improvement in reclassification was higher in these patients than in the total cohort. CONCLUSIONS: The prognostic value of sST2 was not influenced by renal function. On top of other biomarkers, sST2 improved long-term prediction in patients with renal insufficiency even more than in the total cohort.

[Clinical and oncological results of the pathological complete response in rectal cancer after neoadjuvant treatment]. / Resultados clínico-oncológicos de la respuesta patológica completa en el cáncer de recto después de tratamiento neoadyuvante.

INTRODUCTION: Neoadjuvant chemo-radiotherapy is the treatment of choice for rectal cancer in order to reduce local recurrence. Patients with a pathological complete response (PCR) have a better prognosis. The aim of this study was to determine the influence of PCR on the oncological outcomes in our patients. METHODS: All patients with stage ii/iii rectal cancer treated with neoadjuvant chemo-radiotherapy and radical resection between 2007 and 2011 were identified from a prospective database, and grouped based on whether they achieved PCR or not (non-PCR). Clinical, histological and oncological outcome data were compared. RESULTS: A total of 162 patients were included (62% men), with a mean age of 65 years. In terms of pre-operative TNM staging, 82 patients (50%) were T2, 75 (46%) were T3, and 5 (3%) were T4. Forty-two patients (25%) were N1, and 87 (53%) were N2. Low anterior resection and abdominoperineal resection were performed in 125 (77%) and 25 (15%) patients. Forty-three patients (26.5%) had postoperative morbidity. PCR was achieved in 19 patients (11.7%). After a median follow-up of 26 months, there are no recurrences in the PCR group, and in the non-PCR group, local recurrence was 1.4% (P=.78), and distant metastasis was 8.4% (P=.21). Overall survival (P=.39) and survival free of diseases (P=.23) were better in the PCR group, but the differences were not significant. CONCLUSION: Patients with pathological complete response have better oncological outcome.

[Recommendations for the patient during the treatment of colorectal cancer through the enhanced recovery.] / Recomendaciones para el paciente durante el tratamiento del cáncer colorrectal mediante la vía de recuperación intensificada.

It is estimated that colorectal cancer is the cancer disease with the highest incidence in Spain  due to the increase in life expectancy and changes in the lifestyle of the population . Early detection through disease screening programs allows for more effective treatment and a higher survival rate . Advances in treatment have been made, such as targeted therapies, which focus on specifically attacking cancer cells and preventing their growth . However, much remains to be done in terms of prevention and treatment of colorectal cancer. More research and medical advances are required to combat this disease.

Se estima que el cáncer colorrectal es la enfermedad oncológica que presenta mayor incidencia en España  debido al incremento en la esperanza de vida y a los cambios en el estilo de vida de la población . La detección precoz mediante los programas de cribado de la enfermedad permite un tratamiento más efectivo y una mayor tasa de supervivencia . Se han realizado avances en el tratamiento, como las terapias dirigidas, que se centran en atacar específicamente a las células cancerosas y prevenir su crecimiento . Sin embargo, todavía queda mucho por hacer en términos de prevención y tratamiento del cáncer colorrectal. Se requiere más investigación y más avances médicos para combatir esta enfermedad.

Radiation Exposure in Endovascular Surgery According to Complexity: Protocol for a Prospective Observational Study.

In the past decades, we have witnessed tremendous developments in endovascular surgery. Nowadays, highly complex procedures are performed by minimally invasive means. A key point is equipment improvement. Modern C-arms provide advanced imaging capabilities, facilitating endovascular navigation with an adequate open surgical environment. Nevertheless, radiation exposure remains an issue of concern. This study aims to analyze radiation used during endovascular procedures according to complexity, comparing a mobile X-ray system with a hybrid room (fixed X-ray system). This is an observational and prospective study based on a cohort of non-randomized patients treated by endovascular procedures in a Vascular Surgery department using two imaging systems. The study is planned for a 3-year duration with a recruitment period of 30 months (beginning 20 July 2021) and a 1-month follow-up period for each patient. This is the first prospective study designed to describe the radiation dose according to the complexity of the procedure. Another strength of this study is that radiologic variables are obtained directly from the C-arm and no additional measurements are required for feasibility benefit. The results from this study will help us determine the level of radiation in different endovascular procedures, in view of their complexity.

Usefulness of ultrasound-guided tibio-pedal access in patients with critical limb ischemia.

INTRODUCTION: Retrograde access performed guided by fluoroscopy or ultrasound. We aimed to analyze the usefulness of ultrasound in retrograde access in patients with critical limb ischemia. METHODS: Observational analytical study. From December 2013 to June 2019. We included all retrograde accesses that were guided by ultrasound. Our register assesses demographic and clinical data, the vessel used as retrograde access, the procedure performed, the amount of contrast agent used and time of fluoroscopy, access failure, and local complications. RESULTS: On 715 procedures performed, was used ultrasound-guided retrograde access in 25 patients (64% men). The mean age was 74.8 years (45-90), with 92% of diabetics and 32% of chronic renal failure. Two patients with Rutherford stage 4 and 23 with stage 5-6. In 24 (96%) patients the ultrasound-guided puncture was successful, while in one (4%) of them, it was not possible to enter the target vessel. After the punch, was achieved the technical success of revascularization in 19 (79.2%) patients, with 5 (20.8%) in whom did not the arterial injury was not overcome. The arteries used as retrograde access were: anterior tibial 11, posterior tibial 10, and peroneal in 4. The mean of contrast used was 63 mL (9-100 mL) with an average time of 43 min (15-76 min). Complications related did not observe in retrograde access. CONCLUSIONS: Ultrasound-guided retrograde distal access is an effective method that may use as a bailout method in those endovascular procedures in which it is not possible to cross the lesion anterogradely.

Routinely ultrasound surveillance improves outcome after endovascular treatment of peripheral arterial disease: propensity-matched comparisons of clinical outcomes after ultrasound or clinical-hemodynamic based surveillance programs.

BACKGROUND: Endovascular treatment (EVT) has replaced open repair as the first option in intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI) in several centers. However, evidence of the most optimal post-procedural surveillance strategy is sparse. This study aimed to compare two routine surveillance programs after EVT of IC/CLTI: clinical and hemodynamic assessment (CHA) vs. duplex ultrasound (DUS) and clinical/hemodynamic assessment in combination. METHODS: Between February 2012 and December 2015, all patients with EVT of IC/CLTI were allocated to either CHA or DUS-based routine surveillance programs. The allocation-ratio was 1:2 (CHA:DUS), and propensity score matching (PSM) was used to control baseline differences between the groups. Follow-up visits in the CHA group consisted of clinical assessment and ABI at 3, 6, 12 and 24 months. Follow-up visits in DUS group consisted of clinical assessment, ABI, and target vessel DUS at 1, 3, 6, 12, 18 and 24 months. RESULTS: In total, 340 legs in 305 patients suffering from IC/CLTI were included; 111 (33%) in the CHA-group and 229 (67%) in the DUS group. The two groups were identical except for a significantly lower incidence of diabetes mellitus in the CHA group than the DUS group, 55% vs. 72%, respectively (P=006). Based on PSM, the CHA-group vs. the DUS-group was burdened of an increased risk of amputation (12.5% vs. 8.27%, HR=0.41 [95% CI: 0.17-0.96]), and a higher mortality (21.2% vs. 12.8%, HR=0.37 [95% CI: 0.19-0.72]). The reported differences in reintervention rate (7.5% vs. 12.8%, HR=1.12 [95% CI: 0.44-2.84]) were insignificant. The mean follow-up was 317 days (SD=0.214) in the CHA group and 611 days (SD=0.298) in the DUS group. CONCLUSIONS: Our results suggest that DUS-based routine surveillance after EVT of IC/CLTI is superior to CHA-based routine surveillance in improved amputation rate and mortality.

[Colonic volvulus and recurrence of volvulus: what should we do?]. / Vólvulo de colon y recidiva del vólvulo: ¿qué debemos hacer?

INTRODUCTION: Colonic volvulus (CV) is an uncommon disease in our country, which may present clinically as an intestinal obstruction or occlusion. Its diagnosis and therapeutic management remains controversial. The objective of this article is to present our series, analyse the results and establish a therapeutic approach to decrease the recurrence of the volvulus. MATERIAL AND METHODS: A retrospective, descriptive study of patients diagnosed with CV between January 1997 and December 2009. RESULTS: The study included 54 patients, with a mean age of 74 years, who had a total of 89 CV episodes. There was associated disease in 70% of the cases, which included 44% with constipation and 53% with neurological diseases. The volvulus was located in the sigmoid in 87% of cases and in the right colon in 13%. The large majority (92%) of cases had intestinal obstruction. Endoscopic treatment was effective in 61% and urgent surgery was performed in 31% of the cases, and in 40% of the first episodes of CV. There was recurrence of volvulus in 62% of cases treated with surgery, and surgery was performed in 72% of these. In the whole series, surgery was performed in 35 cases (64%), with sigmoidectomy with primary anastomosis being the technique most employed. The overall mortality of the series was 7 cases (12%), with 16% being in cases of surgery due to recurrence. CONCLUSIONS: The diagnostic technique and initial treatment of CV is endoscopic decompression. Early elective surgery prevents the high recurrence rate associated with higher mortality.

Deep vein thrombosis in noncritically ill patients with coronavirus disease 2019 pneumonia: deep vein thrombosis in nonintensive care unit patients.

BACKGROUND: Venous thromboembolic events have been one of the main causes of mortality among hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia. The aim of our study was to describe the prevalence of deep vein thrombosis (DVT) in noncritically ill patients with COVID-19 pneumonia and correlate such observations with the thromboprophylaxis received. METHODS: We performed a prospective cohort study of 67 patients admitted to the hospital for COVID-19 pneumonia. The diagnosis was confirmed using polymerase chain reaction testing of nasopharyngeal specimens. The deep veins were examined using compression duplex ultrasonography with the transducer on B-mode. The patients were separated into two groups for statistical analysis: those receiving low-molecular-weight heparin prophylaxis and those receiving intermediate or complete anticoagulation treatment. Risk analysis and logistic regression were performed. RESULTS: Of the 67 patients, 57 were included in the present study after applying the inclusion and exclusion criteria; 49.1% were women, and the patient mean age was 71.3 years. All 57 patients had undergone compression duplex ultrasonography. Of these 57 patients, 6 were diagnosed with DVT, for an in-hospital rate of DVT in patients with COVID-19 pneumonia of 10.5%. All the patients who had presented with DVT had been receiving low-molecular-weight heparin prophylaxis. The patients receiving prophylactic anticoagulation treatment had a greater risk of DVT (16.21%; 95% confidence interval, 0.04-0.28; P = .056) compared with those receiving intermediate or complete anticoagulation treatment. We also found a protective factor for DVT in the intermediate or complete anticoagulation treatment group (odds ratio, 0.19; 95% confidence interval, 0.08-0.46; P < .05). CONCLUSIONS: Noncritically ill, hospitalized patients with COVID-19 pneumonia have a high risk of DVT despite receipt of correct, standard thromboprophylaxis.

Usefulness of ultrasound-guided tibio-pedal access in patients with critical limb ischemia. / Utilidad de la ecografía en la punción retrógrada distal en la isquemia crítica de extremidades inferiores.

INTRODUCTION: Retrograde access performed guided by fluoroscopy or ultrasound. We aimed to analyze the usefulness of ultrasound in retrograde access in patients with critical limb ischemia. METHODS: Observational analytical study. From December 2013 to June 2019. We included all retrograde accesses that were guided by ultrasound. Our register assesses demographic and clinical data, the vessel used as retrograde access, the procedure performed, the amount of contrast agent used and time of fluoroscopy, access failure, and local complications. RESULTS: On 715 procedures performed, was used ultrasound-guided retrograde access in 25 patients (64% men). The mean age was 74.8 years (45-90), with 92% of diabetics and 32% of chronic renal failure. Two patients with Rutherford stage 4 and 23 with stage 5-6. In 24 (96%) patients the ultrasound-guided puncture was successful, while in one (4%) of them, it was not possible to enter the target vessel. After the punch, was achieved the technical success of revascularization in 19 (79.2%) patients, with 5(20.8%) in whom did not the arterial injury was not overcome. The arteries used as retrograde access were: anterior tibial 11, posterior tibial 10, and peroneal in 4. The mean of contrast used was 63 mL (9-100 ml) with an average time of 43 minutes (15- 76 min). Complications related did not observe in retrograde access. CONCLUSIONS: Ultrasound- guided retrograde distal access is an effective method that may use as a bailout method in those endovascular procedures in which it is not possible to cross the lesion anterogradely.

[Treatment inertia in secondary prevention of cardiovascular disease. FRENA registry]. / Inercia terapéutica en prevención secundaria de enfermedad cardiovascular. Registro FRENA.

BACKGROUND AND OBJECTIVE: Although nowadays there are many cardiovascular disease (CVD) treatment protocols and evidence based guidelines, not many patients achieve the recommended levels for cardiovascular (CV) risk factor (RF) and management of disorders could be improved. Treatment inertia (TI) is the failure of health care providers to initiate or intensify therapy when indicated. The purpose of this study was to quantify TI in secondary CV prevention and identify factors influencing TI. PATIENTS AND METHOD: Observational, transversal study with 1660 patients included in FRENA (The FRENA registry recruited Spanish patients in CVD secondary prevention treated by different specialists), aged 66,3 years, 74% males, 38,5% females, 38,5% coronary heart disease (CHD), 30,8% cerebrovascular disease and 32% peripheral artery disease (PAD). Final variable: TI; three types of inertia where described: treatment failure inertia, RF control inertia and the third one was at least one of the previous. Uni and multivariate analysis were done for each type of inertia. RESULTS: Inertia was detected in 81,5% of the patients. RF control inertia was 85,1% and treatment failure inertia 53%. Diabetic patients are likely to be treated with TI whereas patients with renal insufficiency (RI) or arterial hypertension (AHT) are more likely to be protected against it. There is less treatment failure inertia in cerebrovascular disease or coronary heart disease Vs PAD, AHT and Dyslipemia (DL) where the rate of treatment failure inertia is higher. RF control inertia increases with the coexistence of AHT, DL and diabetes mellitus (DM) and is lower in patients with previous CVD, cerebrovascular disease, AHT and DL. CONCLUSIONS: In high risk patient, TI is present in a high percentage of them. DM, PAD and the coexistence of cardiovascular risk factors are associated with a higher inertia.

Delaying surgery by more than 10 weeks after long-course neoadjuvant radiotherapy in locally advanced rectal cancer patients improves pathologic complete response.

BACKGROUND: We currently do not know the optimal time interval between the end of chemoradiotherapy and surgery. Longer intervals have been associated with a higher pathological response rate, worse pathological outcomes and more morbidity. The aim of this study was to evaluate the effect and safety of the current trend of increasing time interval between the end of chemoradiotherapy and surgery (< 10 weeks vs. ≥ 10 weeks) on postoperative morbidity and pathological outcomes. This study analyzed 232 consecutive patients with locally advanced rectal cancer treated with long-course neoadjuvant chemoradiotherapy from January 2012 to August 2018. 125 patients underwent surgery before 10 weeks from the end of chemoradiotherapy (Group 1) and 107 patients underwent surgery after 10 or more weeks after the end of chemoradiotherapy (Group 2). Results have shown that wait for ≥ 10 weeks did not compromise surgical safety. Pathological complete response and tumor stage was statistically significant among groups. The effect of wait for ≥ 10 weeks before surgery shown higher tumor regression than the first group (Group 1, 12.8% vs Group 2, 31.8%; p < 0.001). On multivariate analysis, wait for ≥ 10 weeks was associated with pathological compete response. Patients from the second group were four time more likely to achieve pathologic complete response than patients from the first group (OR, 4.27 95%CI 1.60-11.40; p = 0.004). Patients who undergo surgery after ≥ 10 weeks of the end of chemoradiotherapy are four time more likely to achieve complete tumor remission without compromise surgical safety or postoperative morbidity.

Role of an age-adjusted D-dimer cutoff level in the diagnosis algorithm of lower limb deep venous thrombosis in outpatients.

OBJECTIVE: Our goal was to analyze the utility of the age-adjusted D-dimer cutoff value in patients with clinically suspected deep venous thrombosis (DVT) in an ambulatory care setting, including distal DVTs. METHODS: This was an observational cohort study of 606 outpatients older than 18 years presenting with low or moderate clinical suspicion of lower limb DVT (measured by Wells scale). D-dimer levels were obtained, and duplex ultrasound was performed (including femoropopliteal and below-knee veins). We calculated sensitivity, specificity, and positive and negative predictive D-dimer values and when to apply the age-adjusted D-dimer cutoff value (D-dimer threshold = age × 10 µg/L). We split patients older than 50 years into 10-year age groups. We constructed receiver operating characteristic curves of the D-dimer test for each group to find the best threshold (defined as the value of D-dimer that gives more specificity, maintaining the maximum possible sensitivity). RESULTS: There were 249 men and 357 women with a mean age of 69.3 years; 41 patients were diagnosed with DVT. At a D-dimer threshold of 250 µg/L, sensitivity was 93%, specificity was 8%, positive predictive value was 7%, and negative predictive value was 94%. When the age-adjusted cutoff level was applied, global sensitivity was 76% and specificity 61%; positive predictive value was 12%, and negative predictive value was 97%. False-negative rate was 24%. We split patients older than 50 years into 10-year age groups: 50 to 60 years, 60 to 70 years, 70 to 80 years, and >80 years. The optimum thresholds were, respectively, 526 µg/L, 442.5 µg/L, 475 µg/L, and 549. µg/L. CONCLUSIONS: In our series, the age-adjusted D-dimer cutoff level is not useful in the diagnostic algorithm of DVT.

Transanal surgery: A tool in the colorectal anastomotic leakage. / La cirugía transanal como herramienta en la dehiscencia de la anastomosis colorrectal.

The treatment of anastomotic leakage after oncological surgery for rectal cancer is a surgical challenge. The goal of this study is to show how transanal surgery combined with the abdominal approach is a very useful tool to decide on individualized treatment depending on the degree of dehiscence and to assist us in its local management. We present three cases of patients with colorectal anastomotic dehiscence. In two, we demonstrate the treatment of acute colorectal leakage and how transanal surgery allows us to confirm its viability and rule out any underlying ischemia. Furthermore, it facilitates good drainage of the adjacent collection as well as the placement of a vacuum system, if necessary, and its subsequent replacements. The last case is a delayed dehiscence with chronic presacral sinus, and its treatment by transanal access for fenestration.

[Diagnosis and treatment of bronchiectasis. Spanish Society of Pneumology and Thoracic Surgery]. / Diagnóstico y tratamiento de las bronquiectasias. SEPAR.

Bronchiectasis is the end result of several different diseases that share principles of management. The clinical course usually involves chronic bronchial infection and inflammation, which are associated with progression. The cause of bronchiectasis should always be investigated, particularly when it can be treated. We recommend evaluating etiology, symptoms, bronchial colonization and infection, respiratory function, inflammation, structural damage, nutritional status, and quality of life in order to assess severity and to monitor clinical course. Care should be supervised by specialized units, at least in cases of chronic bronchial infection, recurrent exacerbations, or when there is a cause that is likely to respond to treatment. Improving symptoms and halting progression are the goals of management, which is based on treatment of the underlying cause and of acute or chronic infections and on the drainage of secretions. Complications that arise must also be treated. Antibiotic prescription is guided by how well infection is being controlled, and this is indicated by the color of sputum and a reduction in the number of exacerbations. We recommend inhaled antibiotics in cases of chronic bronchial infection that does not respond to oral antibiotics, when these cause side effects, or when the cause is Pseudomonas species or other bacteria resistant to oral antibiotics. Inhaled administration is also advisable to treat initial colonization by Pseudomonas species.